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In a strict party-line vote with 20 Republican defections, the House approved legislation Thursday—in a 217 to 213 vote—to gut most of the Affordable Care Act, known as Obamacare, and in doing so to give tax breaks worth more than half a trillion dollars to the wealthiest Americans, health insurers and drug companies.

The vote on “Trumpcare” is the first major legislative victory for President Trump since he took office in January and fulfills a pledge the most extreme right-wingers have been making since Obamacare became law in 2010. Twenty Republicans voted no.

“A lot of us have been waiting seven years to cast this vote,” said House Speaker Paul Ryan in the Republicans’ closing argument. “Many of us are here because we pledged to cast this very vote. To repeal and replace Obamacare. To rescue people from this collapsing law. Are we going to meet this test? Are we going to be men and women of our word? Are we going to keep the promises that we made? Or are we going to falter? No.”

Ryan’s tough-minded posturing came after Republicans said they were acting to save Americans higher insurance premiums and an exodus of private insurance companies across America that participated in the law’s health care exchanges. Republicans made no effort to fix the institutional barriers that cause problems with Obamacare, such as allowing rural states to form interstate compacts to create larger pools that would attract more private insurers.

Instead, they pursued a scorched-earth strategy to deregulate the health insurance industry, despite protests from every medical and patient advocacy group in America that such a move would lead to higher costs and less coverage. They went further, using the repeal legislation to take more than $800 billion away from state-administered Medicaid programs over the next decade, which serve millions of children and provide nursing home care for the elderly—not simply offering the poor a health care safety net. And they repealed the law’s income tax surcharges on the wealthy that funded Obamacare subsidies while additionally giving tax breaks to insurers and drug makers.

“Today this House has an opportunity to do more than fulfill a promise,” said Ryan, never once mentioning the human cost or multibillion-dollar tax giveaways and instead speaking in the vague over-promising manner of President Trump. “We have the opportunity to raise our gaze and set a bold course for our country. We have the opportunity to show we have the resolve to tackle the big challenges in this country before they tackle us. To stop the drift of arrogant big-government policies in our lives and begin a new era of reform based on liberty and self-determination. Giving people choices.”

The House Democrats urged their Republican colleagues to come to their senses and work on a health care bill that would actually fix Obamacare’s real problems while not depriving 24 million Americans of coverage in the next few years—which was the Congressional Budget Office’s estimate of the impact of Ryan’s last repeal bill, which failed to pass in March. Ryan refused to allow the CBO to assess the impacts of the latest legislation before Thursday’s vote. However, numerous analysts have said it would have wider and far more devastating impacts, because it allows insurers to curtail coverage in many ways, from not selling policies to people with pre-existing conditions to rescinding what’s covered in health plans provided by private employers.

House Democratic Leader Nancy Pelosi said Americans will not forget what House Republicans voted for because it will affect every household.

“The American people are engaged. They are paying attention: I’m not saying in a political way; I’m saying in a personal way. A former speaker said all politics is local. In the case of health care, all politics is personal,” Pelosi said, giving the Democrats’ closing statement. “This civics lesson will teach the American people a number of things. As special as we think we are when we come to the floor here, most Americans don’t know who their member of Congress is. But they will now, when they find out that you voted to take away their health care… They will know when you put an age tax on them, or undermine Medicare or Medicaid and the rest. Oh yeah, they’re paying attention because it’s really personal with them and their families.”

Pelosi slammed the Republicans who say they are moderate yet voted yes.

“Our members and colleagues who have the mantle of being a moderate, if you vote for this bill, you have walked the plank from moderate to radical,” she said. “And you’re walking the plank for what—a bill that will not be accepted by the United States Senate? Why are you doing this? Do you believe in what is in this bill? You said they’ll fix it in the Senate. But you have every provision of this bill tattooed on your forehead. You will glow in the dark on this one.”

Before the House began its series of votes Thursday, it was clear that members of Congress and the public were still discovering that the proposal’s fine print includes even more brazen cuts and giveaways to corporate America than they knew. The biggest example, first reported in the Wall Street Journal, is a provision allowing insurers to lessen the benefits covered in insurance policies provided by employers to employees. These are not people covered under the Affordable Care Act, or Obamacare, at all, but who benefited from the ACA’s required coverage provisions.

“Many people who obtain health insurance through their employers—about half of the country—could be at risk of losing protections that limit out-of-pocket costs for catastrophic illnesses, due to a little-noticed provision of the House Republican health care bill to be considered Thursday, health policy experts say,” the WSJ report began. “Insurers in states that obtain the waivers [under the House bill] could be freed from a regulation mandating that they cover 10 particular types of health services, among them maternity care, prescription drugs, mental health treatment and hospitalization.”

This is not the only surprising analysis that’s appeared in the past 24 hours. A New York Timesreport noted how the Trumpcare bill will take billions away from K-12 public schools that’s now used for special education, where specialists are hired to help children with developmental disabilities.

“The new law would cut Medicaid by $880 billion, or 25 percent, over 10 years and impose a ‘per-capita cap’ on funding for certain groups of people, such as children and the elderly—a dramatic change that would convert Medicaid from an entitlement designed to cover any costs incurred to a more limited program,” the Times reported. “School districts receive about $4 billion in Medicaid reimbursements annually.”

There are other stunning summaries of the bill passed by the House. It broadly deregulates the health insurance industry, eliminates the ACA’s patient protection standards, eliminates cost controls and subsidies, and sets a stage to turn state government-delivered care for low-income people into rationed benefits. Those recipients include the most vulnerable elderly and children, not just poor adults.

These results flow from the Trumpcare bill’s specifics, which according to a new Times analysis repeals the Affordable Care Act’s individual mandate to have insurance coverage; repeals the requirements that employers provide insurance; repeals subsidies that help low-to-middle income families pay for policies after 2020; repeals the income tax surcharges that generated those subsidies; lets states keep their Medicaid expansion but turns it into per-capita payments; lets states end requirements that insurers sell policies to people with pre-existing conditions; allows states to waive “essential benefit” requirements; lifts restrictions on what insurers can charge older Americans; offers tax credits instead of subsidies for middle-class families; and encourages health savings accounts.

An economic analysis by Americans for Tax Fairness and Healthcare for America Now, both progressive coalitions, broke down how the Obamacare repeal bill was a massive giveaway to the wealthy, insurers and the drug industry at the expense of people who are now covered or would see premiums skyrocket.

“The GOP plan will deprive 24 million Americans of health care coverage and drive up the cost of coverage for millions more, especially older people and people in rural America. At the same time, it will create tax breaks worth about $600 billion that will mostly go to health insurance companies, prescription drug manufacturers and the wealthy,” their summary said.